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Formulary for Psychotropic Medicines and the Treatment of Minor Physical Ailments This formulary is intended for use by 5 Boroughs Partnership NHS Foundation Trust approved prescribers and its purpose is to ensure that only those medicines that are safe, effective and value for money are used within the Trust. Only medications that have an ‘approved’ status may be initiated within the Trust. Those that have ‘restricted’ status may only be initiated in certain circumstances e.g. following approval from the medical director. Where a service user is admitted onto an inpatient ward and they are already on established on medication that is ‘non-approved’ this can be continued where clinically appropriate. Always ensure that the most up to date version of the formulary and any accompanying guidelines are used. When prescribing for complex individuals e.g. renal impairment, pregnancy contact the medicines management team for advice. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 1 of 67 Version 3 08/12/2011 Contents Page Number Topic Reference 1 Introduction – Psychotropic Medicines Formulary 2-4 Contents 5-8 Hypnotics BNF 4.1.1 NICE TA077 http://guidance.nice.org.uk/TA77/QuickRefGuide/pdf/English British Association for psychopharmacology guidelines http://www.bap.org.uk/docsbycategory.php?docCatID=2 The Ashton Manual http://www.benzo.org.uk/manual/index.htm 9-11 Anxiolytics BNF 4.1.2 NICE CG22 http://guidance.nice.org.uk/CG113 12-23 Antipsychotics BNF 4.2.1 Trust Antipsychotic Prescribing Guidelines NICE CG82 http://guidance.nice.org.uk/CG82/Guidance NICE CG38 http://guidance.nice.org.uk/CG38/Guidance/pdf/English Royal College of Psychiatrists advice on prescribing above BNF upper limits http://bnf.org/bnf/bnf/current/3208.htm 24 - 26 Depot Antipsychotics BNF 4.2.2 Maudsley Prescribing Guidelines 10th Edition, pages 35-41 Royal College of Psychiatrists Consensus Statement on High Dose Antipsychotic Prescribing www.rcpsych.ac.uk/files/pdfversion/CR138.pdf NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 2 of 67 Version 3 08/12/2011 27-29 Antimanic Drugs BNF 4.2.3 Trust http://5boroughswww/MANAGE/library/documents/5BP9002002_lithiumprocedurev2.2.pdf NPSA http://www.nrls.npsa.nhs.uk/resources/?EntryId45=65426 British Association for psychopharmacology guidelines for bipolar disorder http://www.bap.org.uk/pdfs/Bipolar_guidelines.pdf 30-35 Antidepressants BNF 4.3 NICE CG90 http://guidance.nice.org.uk/CG90 NICE CG28 http://guidance.nice.org.uk/CG28 NICE CG91 http://guidance.nice.org.uk/CG91 36-40 CNS Stimulants and Drugs Used for Attention Deficit Hyperactivity Disorder BNF 4.4 NICE CG72 http://www.nice.org.uk/nicemedia/live/12061/42060/42060.pdf British Association for psychopharmacology guidelines on the management of ADHD in adolescents in transition to adult services and in adults http://www.bap.org.uk/pdfs/ADHD_Guidelines.pdf BNF for children http://bnfc.org/bnfc/bnfc/current/3373.htm 41-42 Anticholinergic Medication for the Management of Extrapyramidal Side Effects BNF 4.9.2 43-46 Drugs for Dementia BNF 4.11 NICE-SCIE CG42 http://www.nice.org.uk/nicemedia/live/10998/30320/30320.pdf NICE TA217 http://www.nice.org.uk/nicemedia/live/13419/53619/53619.pdf NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 3 of 67 Version 3 08/12/2011 47-52 Other Drugs That May Be Considered in the Management of Bipolar Disorder 53-55 Drugs approved for ‘off NICE CG38 http://guidance.nice.org.uk/CG38/Guidance/pdf/English British Association for psychopharmacology guidelines for bipolar disorder http://www.bap.org.uk/pdfs/Bipolar_guidelines.pdf Trust Unlicensed medicines procedure label’ use http://nww5boroughsintranet/library/documents/unlicensedmedicinesprocedure.pdf 56-67 Formulary for the treatment of minor physical ailments Laxatives Analgesics Indigestion remedies Sore throat remedies Barrier creams Emollients Non anti-microbial ear drops Non anti-microbial eye drops Treatments for warts, verrucas and coldsores Treatment of haemorrhoids Sunscreens Nutritional supplements NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 4 of 67 Version 3 08/12/2011 Return to Contents Page Hypnotics BNF 4.1.1 Prior to prescribing a hypnotic identify and treat any underlying causes of insomnia. However, it is important to remember that worsening of a mental health condition may disrupt sleep and in this situation a short course of a hypnotic may be appropriate. Hypnotics are licensed for short term use only. Intermittent use better than regular use. Tolerance develops with 3 – 14 days of continued use. Offer advice on sleep hygiene. Keep a sleep chart prior to prescribing. Service users who have not responded to one hypnotic drug from zopiclone, zolpidem or the shorter acting benzodiazepines should not be switched to another as there is a lack of compelling evidence to distinguish between them. The only reason for switching between these drugs is if the service user experiences side effects thought to be directly related to a specific drug. For inpatients always review hypnotics prior to discharge and stop if possible. If hypnotics are to be continued at discharge the GP should be provided with specific instructions about how long they are to be continued for and how to reduce the dose. Service users must be warned that hypnotics may affect their ability to drive or operate machinery as a result of impaired judgement and increased reaction time. This may continue the next day (hangover effect) and the effects of alcohol will also be increased. Visit http://www.dft.gov.uk/dvla/medical.aspx for full guidance, including when the DVLA must be notified of a medical condition and/or treatment. Signposts to local (GREEN) and national (BLUE) prescribing guidelines TRUST NICE TA077 Hypnotic prescribing guidelines Covers the use of the newer hypnotic drugs in the short term management of insomnia http://guidance.nice.org.uk/TA77/QuickRefGuide/pdf/En glish British Association for psychopharmacology guidelines http://www.bap.org.uk/docsbycategory.php?docCatID=2 The Ashton Manual Full guidance on management of withdrawal of benzodiazepines http://www.benzo.org.uk/manual/index.htm BNF Suggested benzodiazepine withdrawal protocol and equivalent doses http://bnf.org/bnf/bnf/current/3139.htm Electronic Medicines Compendium Summary of Product Characteristics for individual drugs www.medicines.org.uk NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 5 of 67 Version 3 08/12/2011 Formulary Status Drug Initial Dose* Maximum Dose* Formulations Available Cost of 28 days treatment Approved (first line) Zopiclone 3.75mg at bedtime 7.5mg at bedtime Tablets £1.49-£1.57** Approved (second line) Temazepam 10mg at bedtime 20mg at bedtime Tablets £1.83-£3.05** Liquid £24.02-£48.05** Zolpidem 5-10mg at bedtime 10mg at bedtime Tablets £1.79** Nitrazepam 5-10mg at bedtime 10mg at bedtime Tablets £2.49-£4.98** Oral suspension £9.80-£19.60** 1-2 tablets at bedtime 5 tablets daily Tablets (cloral betaine 707mg) £11.29-£56.46** Approved (third line) Cloral betaine*** Comments Licensed for up to 4 weeks use. Licensed for up to 4 weeks use. Cloral betaine 707mg is equivalent to chloral hydrate 414mg. Not kept as stock within the Trust – may be a delay in obtaining. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 6 of 67 Version 3 08/12/2011 Formulary Status Drug Chloral hydrate*** Approved (third line) Initial Dose* Maximum Dose* 5-20ml at night 20ml at night Chloral mixture 500mg/5ml Prices vary according to supplier. 2 capsules at bedtime 192mg capsules £7.00-£35.00** Clomethiazole 1-2 capsules (chlormethiazole) at bedtime Restricted Melatonin Formulations Available Cost of 28 days treatment Comments Take well diluted with water. Not kept as stock within the Trust and only available from ‘special order’ manufacturers – may be a delay in obtaining. Melatonin is available as a 2mg modified release tablet (Circadin®) which is licensed for short term treatment of primary insomnia in patients over 55 years. Circadin® is not approved for initiation in adult service users within the Trust. However, Circadin® may be used within the CAMHS service where use of melatonin is considered appropriate (prescription must specify that Circadin® is required - see prescribing advice below). G:\Corporate Pharmacy\Pharmacy Team\WORKING DOCUMENTS\Formulary\5BP melatonin prescribing advice ver01draFINAL 2009-10-28.doc Prices vary according to supplier. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 7 of 67 Version 3 08/12/2011 Formulary Status Not Approved Drug Initial Dose* Maximum Dose* Formulations Available Cost of 28 days treatment Comments Flurazepam, Loprazolam, Lormetazepam, Triclofos sodium, and Zaleplon are not approved for initiation within the Trust. *Usual dose for adults. Dose may vary for young people and elderly – see BNF for details ** Prices based on Drug Tariff November 2012 edition ***Identified in the BNF as drugs considered less suitable for prescribing. Although they should not be considered as drugs of first choice their use may be justifiable in certain circumstances. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 8 of 67 Version 3 08/12/2011 Return to Contents Page Anxiolytics BNF 4.1.2 Some antidepressants are licensed for use in anxiety and related disorders (see BNF section 4.3) and are considered first-line pharmacological treatment. Benzodiazepines licensed for short term relief (2-4 weeks only) of severe anxiety. The use of benzodiazepines to treat short-term ‘mild’ anxiety is not appropriate. Dependence, tolerance and a paradoxical increase in hostility and aggression may develop with regular use. Withdraw benzodiazepines carefully and gradually. Beta-blockers reduce autonomic symptoms such as palpitations and tremor. They do not affect psychological symptoms of anxiety. Invest time in methods to improve medicine adherence (NICE Medicine Adherence – page 5) Signposts to local (GREEN) and national (BLUE) prescribing guidelines NICE CG113 Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults http://guidance.nice.org.uk/CG113 BNF Suggested benzodiazepine withdrawal protocol and equivalent doses http://bnf.org/bnf/bnf/current/3139.htm The Ashton Manual Electronic Medicines Compendium Full guidance on management of withdrawal of benzodiazepines http://www.benzo.org.uk/manual/index.htm Summary of Product Characteristics for individual drugs www.medicines.org.uk NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 9 of 67 Version 3 08/12/2011 Formulary Status Approved Drug Diazepam Initial Dose* Maximum Dose* Formulations Available Cost of 28 days treatment 2mg three times a day 30mg daily in divided doses Tablets £1.98-£2.19** Oral Solution £76.36£381.78** 1-4mg daily in divided doses 4mg daily in divided doses Tablets £3.15-£12.60** Buspirone 5mg two to three times daily. 45mg daily in divided doses. Tablets £24.55-£80.56** Propranolol 40mg once daily 40mg three times daily. Immediate release tablets £0.73-£2.19** 80mg once a day of modified release capsules 160mg once a day of modified release capsules Modified release capsules £5.06-6.76** Lorazepam Comments Long half life likely to cause next day hang over effect – consider effect on driving. Short term use only. Can also be used in rapid tranquilisation – refer to Trust Rapid Tranquilisation Policy for details Slow onset of action – 4 weeks at 10mg three times a day needed for optimum efficacy. Licensed for short-term use only. Poor evidence of effectiveness. Only to be used for anxiety with somatic symptoms such as palpitations, sweating and tremor. Should not be given to patients with a history of asthma or bronchospasm. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 10 of 67 Version 3 08/12/2011 Formulary Status Maximum Dose* Formulations Available Drug Initial Dose* Reserved for use in acute alcohol withdrawal only. Chlordiazep oxide Variable dosing for acute alcohol withdrawal over several days. Not Approved Oxazepam is not approved for initiation within the Trust. Capsules Cost of 28 days treatment Cost varies according to reducing regime prescribed. Comments Long half life likely to cause next day hangover effect – consider effect on driving. *Usual dose for adults. Dose may vary for young people and elderly – see BNF for details ** Prices based on Drug Tariff November 2012 edition NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 11 of 67 Version 3 08/12/2011 Return to Contents Page Signposts to local (GREEN) and national (BLUE) prescribing guidelines Antipsychotics BNF 4.2.1 Physical health checks essential; baseline and annual FBC, LFTs, U+Es, lipids, fasting glucose, weight/BMI, prolactin, blood pressure, ECG. Use prescribed medication monitoring form .http://nww5boroughsintranetcms/MANAGE/library/documents/5BPpre scribedmedicationmonitoringform.pdf Document results in service users notes and repeat more often if necessary. Review for common side effects including EPSEs, weight gain, sexual & menstrual dysfunction. Document findings even if no side effects experienced. The following antipsychotics should be considered as first line treatment where appropriate; risperidone, olanzapine or quetiapine immediate release or any of the typical antipsychotics as listed in the table below. However, choice should always be guided by clinical factors such as previous response, co-morbidities, side effect profile, interacting medication and patient/carer choice. Where one of these three antipsychotics is not chosen first line the reason for this must be recorded in the notes. Clozapine should always be offered (unless not clinically appropriate) when the response to two different antipsychotics, including at least one second generation ‘atypical’ agent has been inadequate. Invest time in methods to improve medicine adherence (NICE Medicine Adherence – page 5) Unless stated otherwise doses stated in this section are those used for the treatment of schizophrenia and other psychoses. Doses used in the management of other conditions such as mania or BPSD may be different – see relevant section of formulary or BNF for details. TRUST Antipsychotic Prescribing Guidelines NICE CG82 Schizophrenia (update) http://guidance.nice.org.uk/CG82/Guidance NICE CG38 Bipolar Disorder http://guidance.nice.org.uk/CG38/Guidance/pdf/E nglish Royal College of Psychiatrists advice on prescribing above BNF upper limits http://bnf.org/bnf/bnf/current/3208.htm BNF For initial doses, advice on dose titration, indications and side effects. http://bnf.org/bnf/bnf/current/3209.htm Electronic Medicines Compendium Summary of Product Characteristics for individual drugs www.medicines.org.uk NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 12 of 67 Version 3 08/12/2011 Oral Antipsychotics Formulary status Drug Approved – Risperidone first line Where one of these drugs is ineffective or not tolerated then another one may be tried – see section below for Olanzapine other second line options Cost of 28 days treatment Initial Dose* Maximum Dose* Formulations Available 2mg in 1-2 divided doses 16mg daily (but see comments) Tablets £0.71£3.43** Doses above 10mg daily only if benefit considered to outweigh the risks. Orodispersible tablets £35.96130.24** Many side effects such as EPSEs are dose related. Liquid £31.10248.77** Comments Orodispersible tablets and liquid are approximately ten times more expensive than tablets. Refer to table for the most cost effective way of prescribing/administering the desired dose. Can also be used in rapid tranquilisation – refer to Trust Rapid Tranquilisation Policy for details 5-10mg daily 20mg daily Tablets £1.81£5.62** Orodispersible tablets are 10% more expensive than ordinary tablets – see cost comparison table. Orodispersible tablets £16.6160.01** Refer to table for the most cost effective way of prescribing/administering the desired dose. Can also be used in rapid tranquilisation – refer to Trust Rapid Tranquilisation Policy for details NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 13 of 67 Version 3 08/12/2011 Oral Antipsychotics Formulary status Drug Approved – first line Where one of these drugs is ineffective or not tolerated then another one may be tried – see section below for other second line options Quetiapine Initial Dose* 25mg twice daily Maximum Dose* Formulations Available 750mg daily Tablets Cost of 28 days treatment £2.73£28.79** Comments Can be given with or without food. Refer to table for the most cost effective way of prescribing/administering the desired dose. Can also be used in rapid tranquilisation – refer to Trust Rapid Tranquilisation Policy for details Chlorproma zine 25mg 3 times a day 1000mg daily Tablets £5.16£21.84** Oral solution £6.57£51.32** Levomepro mazine 2550mg daily in divided doses 1000mg daily Tablets £6.75£270.13** Perphenazi ne 4mg 3 times daily 24mg daily Tablets 28.77£57.54**** NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 14 of 67 Version 3 08/12/2011 Oral Antipsychotics Formulary status Drug Initial Dose* Approved – Trifluoperazi 2-4mg first line ne daily in divided Where one doses of these drugs is Haloperidol 0.5–3mg ineffective 2–3 or not times tolerated daily or then 3–5mg another one 2–3 may be tried times – see daily in section severely below for affected other or second line resistant options patients Flupentixol 3-9mg twice daily Maximum Dose* Formulations Available 6mg daily Tablets Oral solution 30mg daily 18mg daily Cost of 28 days treatment Comments £2.05£6.16**** £32.48£97.44** Capsules Tablets £2.20£18.76** Liquid £0.62£18.69**** Tablets £7.80£23.39** Carry out ECG prior to commencing. Can also be used in rapid tranquilisation – refer to Trust Rapid Tranquilisation Policy for details NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 15 of 67 Version 3 08/12/2011 Oral Antipsychotics Formulary status Drug Zuclopenthi Approved – xol first line Where one of these Sulpiride drugs is ineffective or not tolerated then another one may be tried – see section below for other second line options Cost of 28 days treatment Initial Dose* Maximum Dose* Formulations Available 2030mg daily in divided doses 200400mg twice daily 150mg daily (max single dose 40mg) Tablets £4.51£33.85** 800mg daily in predomina ntly negative symptoms. 2.4g daily in predomina ntly positive symptoms. Tablets £14.20£39.85** (negative) 119.56** (positive) £47.38£94.75** (negative) £284.26** (positive) Oral solution Comments NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 16 of 67 Version 3 08/12/2011 Oral Antipsychotics Formulary status Drug Amisulpride Approved – second line An alternative drug from the first line section may also be considered as a possible second line option Aripiprazole Initial Dose* Maximum Dose* Formulations Available 400mg – 800mg daily in divided doses 1200mg daily Tablets 1015mg once daily (oral) 30mg daily Cost of 28 days treatment £10.15£87.91** Comments For predominantly negative symptoms use 50-300mg daily Refer to table for the most cost effective way of prescribing/administering the desired dose. Tablets £96.04192.08** Orodispersible tablets £95.74£191.48**** Liquid – restricted (see below) Limited evidence of additional efficacy at doses above 15mg daily unless prescribed in combination with an enzyme inducer such as carbamazepine. Refer to table for the most cost effective way of prescribing/administering the desired dose. Can be used in rapid tranquilisation – refer to Trust Rapid Tranquilisation Policy for details and dosages. IM injection (see comments) Benperidol 0.251.5mg daily in divided doses 1.5mg daily Tablets £24.44£146.64** Only licensed for control of deviant antisocial sexual behaviour NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 17 of 67 Version 3 08/12/2011 Oral Antipsychotics Formulary status Drug Quetiapine Approved – XL second line An alternative drug from the first line section may also be considered as a possible second line option Initial Dose* Maximum Dose* Formulations Available XL formula tion: 300mg once daily 800mg once daily XL tablets Cost of 28 days treatment £79.33£211.12** Comments Consider the XL formulation in situations where a rapid titration is required or where once daily administration would be beneficial. In all other situations use quetiapine immediate release where quetiapine is the chosen antipsychotic. Absorption affected by food, to maintain consistent levels give as a single night time dose (without food) See prescribing advice below: G:\Corporate Pharmacy\Pharmacy Team\WORKING DOCUMENTS\Formulary\5BP AZ Seroquel XL awareness cam Refer to for table he most cost effective way of prescribing/administering the desired dose. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 18 of 67 Version 3 08/12/2011 Oral Antipsychotics Formulary status Drug Clozapine (Clozaril®) Use in Treatment Resistant Schizophre nia or psychosis in Parkinson’ s disease only Restricted – due to high cost use must be agreed with locality pharmacist NonApproved Initial Dose* 12.5mg once daily Maximum Dose* Formulations Available 900mg daily Tablets Cost of 28 days treatment £5.40£194.04**** Comments Only drug licensed and effective for Treatment Resistant Schizophrenia. Clozapine should always be offered (unless not clinically appropriate) when the response to two different antipsychotics, including at least one atypical has been inadequate. Blood tests are mandatory. See SOP for commencing and maintaining clozapine treatment on the ward: http://5boroughswww/MANAGE/library/documents/clozso p06.pdf Service user, prescriber and pharmacist must all be registered with the Clozaril Patient Monitoring Service. Aripiprazole liquid 1015mg daily 30mg daily 1mg/ml liquid £191.46£574.39**** Limited evidence of increased efficacy at doses above 15mg daily unless prescribed in combination with an enzyme inducer such as carbamazepine. Orodispersible tablets are available – see above. Paliperidone is not approved for initiation within the Trust – see http://5boroughswww/MANAGE/library/documents/paliperidonefinalevaluation.pdf for further details Asenapine, prochlorperazine, pimozide and pericyazine are not approved for initiation within the Trust. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 19 of 67 Version 3 08/12/2011 Short Acting IM Antipsychotics Formulary status Drug Initial Dose* Approved – see comments Maximum Dose* Formulations Available Cost of 28 days treatment Comments Aripiprazole Refer to Trust Rapid Tranquilisation Policy IM injection N/A Choice of medication for rapid tranquilisation should be based on previous response, likely side effects, presentation of the service user and any physical health problems - refer to Trust Rapid Tranquilisation Policy for full list of options. Haloperidol refer to Trust Rapid Tranquilisation Policy IM injection N/A Must not be confused with haloperidol decanoate depot injection. Choice of IM medication for rapid tranquilisation should be based on previous response, likely side effects, presentation of the service user and any physical health problems, therefore may be appropriate to use haloperidol first line for rapid tranquilisation - refer to Trust Rapid Tranquilisation Policy for full list of options. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 20 of 67 Version 3 08/12/2011 Short Acting IM Antipsychotics Formulary status Drug Initial Dose* Approved – see comments Maximum Dose* Formulations Available Cost of 28 days treatment Comments Olanzapine Refer to Trust Rapid Tranquilisation Policy IM injection N/A Choice of medication for rapid tranquilisation should be based on previous response, likely side effects, presentation of the service user and any physical health problems - refer to Trust Rapid Tranquilisation Policy for full list of options. Zuclopenthixol acetate refer to Trust Rapid Tranquilisation Policy 50mg/ml IM injection N/A Must not be confused with zuclopenthixol decanoate depot injection. Refer to Trust Rapid Tranquilisation Policy for information on appropriate use. *Usual dose for adults. Dose may vary for young people and elderly – see BNF for details ** Prices based on Drug Tariff November 2012 **** Prices based on BNF September 2012 edition 64 NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 21 of 67 Version 3 08/12/2011 Return to Start of Antipsychotic Section Cost effective doses costs for Atypical Antipsychotics Cost for 28 days supply Formulation Drug Amisulpiride Aripiprazole Olanzapine Quetiapine Dose Tablet Modified Release Oral dispersible Liquid 200mg BD 1 x 200mg £10** £62** 400mg BD 2x 200mg £123** 600mg BD 3 x 200mg £30** 10mg OD 1 x 10mg £96** 1 x 10mg £96**** £192**** 15mg OD 1 x 15mg £96** 1 x 15mg £96**** £287**** 20mg OD 2 x10mg £192** 2 x 10mg £192**** £383**** 25mg OD 1x15mg + 1x10mg £192** 1x10mg + 1x15mg £192**** £479**** 30mg OD 1 x 30mg £192** 2 x 15mg £192** 2 x 15mg £192**** £574**** 5mg BD 1 x 5mg £4** 2 x 2.5mg £2** 1 x 5mg 10mg OD 1 x 10mg £3** 15mg OD 1 x 15mg £4** 1 x 15mg £45** 10mg BD 1 x 10mg £6** 1 x 10mg £60** 20mg ON 2 x 10mg £6** 1 x 10mg £60** 150mg BD 1 x 150mg £8** £20** 300mg OD 200mg BD £185** 1x5mg + 1x15mg £192** £33** 1 x 10mg £30** 1 x 300mg £79** 1x 200mg £8** NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 22 of 67 Version 3 08/12/2011 300mg BD 1 x 300mg £11** 600mg OD 400mg BD 1x400mg + 1x200mg £158** 2x400mg £211** 2x300mg + 1x200mg £211** 2 x 200mg £16 ** 800mg OD Risperidone 2x300mg £159** 1mg BD 1 x 1mg £2** 1 x 1mg £40 ** £31 ** 2mg OD 1 x 2mg £1** 1 x 2mg £37 ** £31** 3mg OD 1x3mg £1** 1 x 3mg £28 ** £47** 2mg BD 1 x 2mg £2** 1x 2mg £72 ** £62** 4mg OD 1 x 4mg £1** 1 x 4mg £33 ** £62** 5mg OD 1 x 3mg + 1 x 2mg £2** 1 x 1mg + 1 x 4mg £52 ** £78** 3mg BD 1 x 3mg £2 ** 1 x 3mg £56 ** £93** 6mg OD 2 x 3mg £2 ** 2 x 3mg £56 ** £93** 1 x 4mg £65 ** 1 x 1mg + 1 x 4mg £104 ** £124** 4mg BD 2 x 2mg £2 ** 1 x 3mg + 1 x 2mg £3 5mg BD ** Doses shown are the most cost effective, if strengths shown are not available please source £155** ** Prices based on Drug Tariff November 2012 edition **** Prices based on BNF September 2012 edition 64 NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 23 of 67 Version 3 08/12/2011 Return to Contents Page Signposts to local (GREEN) and national (BLUE) prescribing guidelines Depot Antipsychotics BNF 4.2.2 Physical health checks essential: baseline and annual FBC, LFTs, U+Es, lipids, fasting glucose, weight, prolactin, blood pressure, ECG. Use prescribed medication monitoring form. .http://nww5boroughsintranetcms/MANAGE/library/documents/5BPpre scribedmedicationmonitoringform.pdf Document results in service users notes and repeat more often if necessary. Review for common side effects including EPSE, weight gain, sexual & menstrual dysfunction. Document findings in notes, even if no side effects experienced. Clozapine should always be offered (unless not clinically appropriate) when the response to two different antipsychotics, including at least one second generation ‘atypical’ agent has been inadequate. Offer depot medication where the service user would prefer this or where treatment adherence is a problem. Whilst depots may not necessarily improve adherence they do allow adherence to be monitored more easily. Selection should be influenced by previous response, co-morbidities, side effect profile, patient/carer choice, interacting medication & cost. Invest time in methods to improve medicine adherence (NICE Medicine Adherence – page 5) TRUST Antipsychotic Prescribing Guidelines NICE CG82 Schizophrenia (update) http://guidance.nice.org.uk/CG82/Guidance NICE CG38 Bipolar Disorder http://guidance.nice.org.uk/CG38/Guidance/pdf/English MAUDSLEY PRESCRIBING GUIDELINES 10th Edition, pages 35-41 Royal College of www.rcpsych.ac.uk/files/pdfversion/CR138.pdf Psychiatrists Consensus Statement on High Dose Antipsychotic Prescribing BNF For further advice on dose titration, indications and side effects. http://bnf.org/bnf/bnf/current/3263.htm Electronic Medicines Compendium Summary of Product Characteristics for individual drugs www.medicines.org.uk NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 24 of 67 Version 3 08/12/2011 First Generation (Typical Antipsychotics) Formulary Status Drug Test Dose* Approved Haloperidol (Haldol Decanoate®) 25-50mg Pipotiazine palmitate (Piportil Depot®) 25mg Fluphenazine decanoate (e.g. Modecate®) Dose Range* Cost of 28 days treatment Comments 50mg - 300mg every 4 weeks (half the dose if given every 2 weeks) 50 – 200mg every 4 weeks £3.82£15.18**** Contains sesame oil. £16.29£53.30**** Contains sesame oil. 12.5mg 12.5mg – 100mg every 25 weeks £2.25£17.58** Contains sesame oil. Flupentixol decanoate (Depixol®) 20mg 20mg - 400mg every one to four weeks £1.28£7.36**** Contains fractionated coconut oil. Zuclopenthix ol decanoate (Clopixol®) 100mg 200mg - 600mg £3.15Every one to £37.81** four weeks Contains fractionated coconut oil. Must not be confused with zuclopenthixol acetate IM injection Clopixol Acuphase®) NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 25 of 67 Version 3 08/12/2011 Second generation (Atypical antipsychotics) Formulary Status Drug Test Dose* Restricted Approval must be sought from the Medical Director before prescribing (application form below) Risperidone (Risperdal Consta®) See comments Dose Range* 25 - 50mg every 2 weeks Cost of 28 days treatment £159.38 to £285.52**** Comments If approved: Service user must have a minimum of 3 days oral risperidone prior to first injection to ensure tolerance. No intramuscular test dose required. The dose of oral risperidone guides initial depot dose: Up to 4mg/day oral = 25mg i/m every 2/52 Over 4mg/day oral = 37.5mg i/m every 2/52 Continue oral risperidone for at least 6 weeks after starting depot then slowly discontinue over 1-2 weeks according to tolerance. This is because drug release from the depot formulation is delayed by 3 weeks. G:\Corporate Pharmacy\Pharmacy Team\REQUEST FORMS FOR NEW DRUGS\Risperdal Consta application to Medical Director version 4.doc . Dose adjusted according to response in increments of 12.5mg at a minimum interval of 12 weeks. For advice on switching from a typical depot to Risperdal Consta® contact a medicines management pharmacist. Not Approved Olanzapine Embonate (ZypAdhera®) – Contact Medicines Management Committee for more details *Usual dose for adults. Dose may vary for elderly – see BNF for details ** Prices based on Drug Tariff November 2012 edition **** Prices based on BNF September 2012 edition 64 NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 26 of 67 Version 3 08/12/2011 Return to Contents Page Antimanic Drugs BNF 4.2.3 Used to treat acute symptoms and to prevent recurrence of mania or hypomania. Long-term treatment of bipolar disorder should continue for at least two years from the last manic episode and up to five years if the patient has risk factors for relapse. Avoid antidepressant drugs in patients with rapid-cycling bipolar disorder, recent history of hypomania/mania, or rapid mood fluctuations. .Carry out regular monitoring of physical health and side effects. Use prescribed medication monitoring form http://nww5boroughsintranetcms/MANAGE/library/documents/5 BPprescribedmedicationmonitoringform.pdf The doses of olanzapine, risperidone and quetiapine stated in this section are for the treatment of mania only – for other indications see relevant section of the formulary or BNF. Invest time in methods to improve medicine adherence (NICE Medicine Adherence – page 5) Please also refer to page 42 of this document – Other drugs that may be considered in the management of bipolar disorder. Signposts to local (GREEN) and national (BLUE) prescribing guidelines TRUST Procedure for lithium initiation http://5boroughswww/MANAGE/library/documents/5BP90 02002_lithiumprocedurev2.2.pdf NICE CG38 covers the use of antimanic drugs in the management of bipolar disorder http://guidance.nice.org.uk/CG38/Guidance/pdf/English NPSA PSA005 see NPSA alert on regular blood and lithium level monitoring http://www.nrls.npsa.nhs.uk/resources/?EntryId45=6542 6 British Association for psychopharmacology guidelines for bipolar disorder http://www.bap.org.uk/pdfs/Bipolar_guidelines.pdf BNF For initial doses, advice on dose titration, indications and side effects. http://bnf.org Electronic Medicines Compendium Summary of Product Characteristics for individual drugs www.medicines.org.uk NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 27 of 67 Version 3 08/12/2011 Formulary Status Approved Drug Lithium Carbonate m/r tablets (Priadel®) Initial Dose* 200-400mg daily Maximum Dose* Adjust dose according to response and serum levels. Usual maximum 1.2g daily Formulations Available Cost of 28 days treatment Tablets £0.64 – £2.81**** Comments Adjust dose to achieve target serum levels. Usual target serum lithium levels are 0.4-1.0 mmol/litre. Take serum levels 12 hours after a dose. Where lithium is initiated Priadel® should always be prescribed. However, if a service user is already established on another brand then this should be continued as different brands have different bioavailabilities. The brand of lithium should always be specified on the prescription. Lithium Citrate (Priadel®) 520mg/5ml liquid 1.04-3.12g daily in 2 divided doses (patients less than 50kg 520mg twice daily) Adjust dose according to response and serum levels Liquid £10.47£31.41**** Adjust dose to achieve target serum levels. Usual target serum lithium levels are 0.4-1 mmol/litre take serum levels 12 hours after a dose. Where lithium is initiated Priadel® should always be prescribed. However, if a service user is already established on another brand then this should be continued as different brands have different bioavailabilities. 5ml Priade®l liquid (520mg lithium citrate) is equivalent to 200mg lithium carbonate (200mg Priadel® tablet). NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 28 of 67 Version 3 08/12/2011 Formulary Status Drug Initial Dose* Approved Semisodium valproate (Depakote®) Approved (second line) Carbamazepine 400mg daily in divided doses 750mg daily in 2-3 divided doses Maximum Dose* Formulations Available Cost of 28 days treatment 2g daily Tablets £13.63£36.28** 1.6g daily Tablets £10.03– £11.16** Modified Release £5.20£20.16** Comments Liquid £11.20£44.80** Should not be routinely used for treating acute mania. For patients who present with mania who are already taking carbamazepine the dose should not routinely be increased. May be considered if a combination of first line prophylactic agents is ineffective (lithium with valproate, lithium with olanzapine, or valproate with olanzapine) Avoid changing brands – variations in bioavailability. *Usual dose for adults. Dose may vary for elderly – see BNF for details ** Prices based on Drug Tariff November 2012 edition **** Prices based on BNF September 2012 edition 64 NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 29 of 67 Version 3 08/12/2011 Return to Contents Page Antidepressants BNF 4.3 Licensed for depressive illness. Review the service user regularly for side effects and document findings in the notes. Use prescribed medication monitoring form .http://nww5boroughsintranetcms/MANAGE/library/documents /5BPprescribedmedicationmonitoringform.pdf Treatment with an antidepressant should usually be continued for at least 6 months after remission of an episode of depression. Selection should be influenced by previous response, comorbidities, side effect profile, patient/carer choice, interacting medication & cost. Be aware of the need to exercise caution when switching antidepressants due to the increased risk of side effects and serotonin syndrome – contact a pharmacist for advice. Invest time in methods to improve medicine adherence (NICE Medicine Adherence – page 5) Signposts to local (GREEN) and national (BLUE) prescribing guidelines NICE CG90 Depression – the treatment and management in adults http://guidance.nice.org.uk/CG90 NICE CG28 Depression in children and young people: identification and management in primary, community and secondary care http://guidance.nice.org.uk/CG28 NICE CG91 Depression with a chronic physical health problem http://guidance.nice.org.uk/CG91 BNF For advice on dose titration, indications and side effects. http://bnf.org/bnf/bnf/current/3294.htm Electronic Medicines Compendium Summary of Product Characteristics for individual drugs www.medicines.org.uk NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 30 of 67 Version 3 08/12/2011 Formulary Status Approved (First Line) Where one of these drugs is ineffective or not tolerated then another one may be tried – see section below for other second line options Drug Citalopram Fluoxetine Paroxetine Sertraline Initial Dose* Max Dose* 20mg 40mg daily once daily 20mg 60mg once once daily daily 20mg 50mg once once daily daily 50mg daily 200mg daily Formulations Available Cost of 28 days treatment Comments Tablets £0.86-£1.06** 4 drops (8mg) is equivalent in therapeutic effect to a 10mg tablet. Oral drops (40mg/ml) £8.71-£17.42** Capsules £0.75-£2.24** Use 20mg capsules only – 60mg capsules cost £48.90** Liquid £9.80-£29.40** Tablets £1.76-£4.00** Oral suspension £17.02£42.56** Long half life – Lower rate of discontinuation symptoms but need to exercise caution when switching from fluoxetine to other antidepressants. Higher rate of discontinuation syndrome due to short half life. Not suitable for service users who are likely to be poorly compliant. Tablets £1.06-£2.66** NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 31 of 67 Version 3 08/12/2011 Formulary Status Approved (Second line) Drug Amitriptyline An alternative drug from the first line section may also Clomipramine be considered as a possible Flupenthixol second line option Initial Dose* Max Dose* 75mg daily in divided doses or as a single dose at bedtime 200mg daily at bedtime 10mg daily 1mg in the morning Formulations Available Cost of 28 days treatment Comments Tablets £2.04-£3.04** Oral solution £48.05£68.32** 250mg daily Capsules £1.44-£9.75** 225mg MR Capsules £8.83-£26.49** MR capsules to be taken once daily. 3mg daily (doses above 2mg in divided doses) Tablets £2.69-£4.08** Last dose before 4pm. Discontinue if no response after one week at maximum dose. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 32 of 67 Version 3 08/12/2011 Formulary Status Approved (Second line) Drug Initial Dose* Max Dose* Formulations Available Cost of 28 days treatment Imipramine Up to 75mg daily in divided doses 200mg in Tablets divided doses (up to 150mg can be given as a single dose at bedtime) £3.21-£8.56** Lofepramine 140mg daily in divided doses 210mg daily in divided doses £13.45£20.18** 15-30mg daily at bedtime 45mg daily at bedtime or in 2 divided doses. Tablets Orodispersible tablets £1.81-£2.40** 300mg daily 600mg daily Tablets £11.99-£23.99** 10mg daily 150mg daily Tablets £7.58£113.70** An alternative drug from Mirtazapine the first line section may also be considered as a Moclobemide possible second line option Nortriptyline Tablets Oral Suspension £41.44£62.16** £2.45-£2.82** Comments Less toxicity in overdose than the other Tricyclic antidepressants. 15mg and 45mg orodispersible tablets are cheaper than the regular tablets NB: Knowsley and St Helens locality pharmacy only stock orodispersible tablets. Consider dietary restrictions. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 33 of 67 Version 3 08/12/2011 Formulary Status Approved (Second line) Drug Initial Dose* Max Dose* Formulations Available Cost of 28 days treatment Reboxetine 4mg twice daily 12mg daily Tablets £17.64£26.47** Trazadone An alternative drug from the first line section may also be considered as a possible Venlafaxine second line option 150mg daily in divided doses after food or as a single dose at bedtime 300mg daily Capsules £3.36-£5.91** Tablets £3.99-£7.98** Liquid £111.72£223.44** 37.5mg twice daily 375mg daily Tablets £2.62-£7.87** Comments Monitor blood pressure, particularly at doses above 225mg. Higher rate of discontinuation symptoms due to short half life. Venlafaxine MR 75mg 225mg once once daily daily Capsules £22.08£58.89** Monitor blood pressure, particularly at doses above 225mg. Higher rate of discontinuation symptoms due to short half life. Tablets - £33.60** NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 34 of 67 Version 3 08/12/2011 Formulary Status Approved (third line) Non approved Drug Initial Dose* Formulations Available Max Dose* Cost of 28 days treatment Duloxetine 60mg daily 60mg daily Capsules £27.72** Escitalopram 10mg daily 20mg daily Tablets £14.91£25.20** Oral drops £18.82£37.63**** Comments Fluvoxamine, Agomelatine, Phenelzine, Isocarboxazid, Tranylcypromine, Doxepin, Trimipramine, Mianserin, St Johns Wort Dosulepin - NICE states that dosulepin should not be prescribed due to increased cardiac risk and toxicity in overdose. *Usual dose for adults. Dose may vary for young people and elderly – see BNF for details ** Prices based on Drug Tariff November 2012 edition **** Prices based on BNF September 2012 64 edition NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 35 of 67 Version 3 08/12/2011 Return to Contents Page CNS Stimulants and drugs used for attention deficit hyperactivity disorder BNF 4.4 Drug treatment for ADHD should only be initiated by a healthcare professional with expertise in ADHD. Treatment of ADHD is usually initiated during childhood or adolescence and may need to be continued into adulthood. Drug treatment of ADHD should be part of a comprehensive treatment programme that includes psychological, behavioural and educational advice and interventions. Drug treatment must take into account co-morbid conditions (e.g. epilepsy, Tourette syndrome and tic disorders), possible side effects, potential for drug misuse and the preferences of the service user or their carer. See BNF for children for guidance on dose titration. Measure weight and height at 3 and 6 months after the start of treatment and then every 6 months. Monitor heart rate and blood pressure and record on a centile chart before and after each dose change and at each review. The need to continue drug treatment for ADHD should be reviewed at least annually. This may involve suspending treatment. Please note that the doses stated below are for children and adolescents. Initiation of treatment for of ADHD in adults is not licensed or commissioned within the Trust. Signposts to local (GREEN) and national (BLUE) prescribing guidelines NICE CG72 Covers the diagnosis and management of ADHD in children, young people and adults, including monitoring and management of side effects. http://www.nice.org.uk/nicemedia/live/12061/42060/42060.pdf British Association for psychopharmacology guidelines on the management of ADHD in adolescents in transition to adult services and in adults http://www.bap.org.uk/pdfs/ADHD_Guidelines.pdf BNF http://bnf.org/bnf/bnf/current/3373.htm BNF for children http://bnfc.org/bnfc/bnfc/current/3373.htm Electronic Medicines Compendium Summary of Product Characteristics for individual drugs www.medicines.org.uk NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 36 of 67 Version 3 08/12/2011 CNS Stimulants and drugs used for attention deficit hyperactivity disorder BNF 4.4 Formulary Status Drug Approved - Methylphenidate First Line Initial Dose* Standard release tablets: Child 4-6 years 2.5mg twice daily Maximum Dose* Signposts to local (GREEN) and national (BLUE) prescribing guidelines Cost of 28 Formulations days Available treatment Standard release tablets: Standard release tablets (brands include Child 4 -6 years Equasym® and £1.511.4mg/kg daily in 2-3 Ritalin®) £14.49** divided doses Child 6-18 years Child 6-18 licensed max 60mg years 5 mg 1- daily in 2-3 divided 2 times daily doses but may be increased to 2.1mg/kg (max 90mg daily) under the direction of a specialist. £1.51£45.36** Comments Controlled drug requirements apply. Discontinue if no response after one month. If the effect wears off in the evening (with rebound hyperactivity) then a trial of a dose at bedtime may be appropriate. Equasym® and Ritalin® tablets may be halved. Controlled drug requirements apply. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 37 of 67 Version 3 08/12/2011 CNS Stimulants and drugs used for attention deficit hyperactivity disorder BNF 4.4 Methylphenidate Approved – first line Concerta® XL: Concerta® XL: Signposts to local (GREEN) and national (BLUE) prescribing guidelines Modified release tablets Child 6-18years max (Concerta® XL) £29.11Child 6-18 licensed dose 54mg £118.86** years 18mg once daily but may be once daily in increased to the morning 2.1mg/kg daily (max 108mg daily) under the direction of a specialist. Discontinue if no response after one month. Different modified release preparations have different release profiles and different dosages. Therefore the brand of modified release methylphenidate should always be stated on the prescription and if newly initiated should be Concerta® XL. However, if a service user is already established on another brand of modified release methylphenidate when they come into our care then the usual brand should be continued (please notify pharmacy immediately as this may need to be ordered in). Total daily dose of 15mg standard release methylphenidate is considered equivalent to Concerta® XL 18mg once daily. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 38 of 67 Version 3 08/12/2011 CNS Stimulants and drugs used for attention deficit hyperactivity disorder BNF 4.4 Approved – Atomoxetine Second line Child over 6 years (body weight under 70kg) 500 micrograms/k g daily Child over 6 years (body weight over 70kg) 40mg daily Child over 6 years Capsules (body weight under 70kg) usual maintenance dose 1.2mg/kg but may be increased to 1.8mg/kg daily (max 120mg daily) under the direction of a specialist. Child over 6 years (body weight under 70kg) usual maintenance dose 80mg daily but may be increased to max 120mg daily under the direction of a specialist. Signposts to local (GREEN) and national (BLUE) prescribing guidelines £62.46124.92** May be suitable where stimulant diversion is a problem, or where dopaminergic side effects such as tics, anxiety and stereotypies occur with methylphenidate or dexamphetamine. Monitor for agitation, irritability, suicidal thinking and self harm, especially during the initial months of treatment or after a change in dose. Warn patients and their carers about the rare potential for liver damage with atomoxetine and the signs to look for (routine LFTs not recommended) Total daily dose may be given either as a single dose in the morning or in 2 divided doses with the last dose no later than early evening. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 39 of 67 Version 3 08/12/2011 CNS Stimulants and drugs used for attention deficit hyperactivity disorder BNF 4.4 Approved – Dexamphetamine second line Child 6-18 Child 6-18 years Tablets years 5-10mg usual max 1mg/kg once daily daily, up to 20mg (40mg daily has been required in some children). Maintenance dose given in 2-4 divided doses. Signposts to local (GREEN) and national (BLUE) prescribing guidelines £18.81£150.48** Controlled drug requirements apply. Use with caution in those likely to be at risk of stimulant misuse or diversion. Tablets can be halved. *Usual dose for children and adolescents. Dose may vary for adults – see BNF for details ** Prices based on Drug Tariff November 2012 edition **** Prices based on BNF September 2012 edition 64 NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 40 of 67 Version 3 08/12/2011 Return to Contents Page Anticholinergic medication for the management of extrapyramidal side effects B.N.F 4.9.2 Do not use routinely in the absence of extrapyramidal side effects. Tardive dyskinesia is not improved by anticholinergic drugs and may be made worse. All anticholinergics have the potential to be abused. See BNF for further information on dose titration. Signposts to local (GREEN) and national (BLUE) prescribing guidelines BNF http://bnf.org/bnf/bnf/current/3654.htm Electronic Medicines Compendium Summary of Product Characteristics for individual drugs www.medicines.org.uk NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 41 of 67 Version 3 08/12/2011 Formulary Status Approved (First Line) Drug Procyclidine Initial Dose* Maximum Dose* By mouth: By mouth: 30mg 2.5mg 3 times daily in 2-4 divided daily doses By intramuscular injection (for acute dystonia only): 5-10mg, usually effective in 5-10 minutes but may need 30minutes for relief. Formulary Status Approved (second line) Drug Orphenadrine Trihexyphenidyl (benzhexol) Initial Dose* 150mg daily in divided doses 1mg daily Maximum Dose* 400mg daily in divided doses 20mg daily in 3-4 divided doses Cost of Formulations 28 days Available treatment Tablets £5.10£10.20** Syrup £17.64£63.84** Intramuscular injection £1.49**** per dose Cost of Formulations 28 days Available treatment Tablets £60.48£161.28** Liquid £20.16£53.76**** £3.38£20.16** Tablets Syrup Comments Only use liquid if the service user has swallowing difficulties. Comments £1.12£22.40** *Usual dose for adults. Dose may vary for young people and elderly – see BNF for details NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 42 of 67 Version 3 08/12/2011 ** Prices based on Drug Tariff November 2012 edition **** Prices based on BNF September 2012 edition 64 Return to Contents Page Drugs for Dementia BNF 4.11 Donepezil, Galantamine and Rivastigmine are recommended as options for the management of people with Alzheimer’s disease of mild to moderate severity (MMSE score 10-20 points) Rivastigmine is also licensed for mild to moderate dementia associated with Parkinson’s disease. Assess patient every 6 months and continue drug treatment only if MMSE score remains at or above 10 points. Dose related cholinergic side effects are common so treatment should be started with a low dose and increased gradually according to response and tolerability. An ECG is advisable prior to starting treatment with donepezil, galantamine and rivastigmine due to their potential to cause cardiac side effects including bradycardia and arrhythmias. Memantine is approved for use within the Trust for treatment of severe Alzheimer’s disease or for those with moderate Alzheimer’s disease who are intolerant to or have a contraindication to treatment with an AChEI. Memantine is approved for use as monotherapy only, and must not be prescribed in combination with an AChEI. Invest time in methods to improve medicine adherence (NICE Medicine Adherence – page 5) Signposts to local (GREEN) and national (BLUE) prescribing guidelines NICE-SCIE CG42: Full Guideline on supporting people with dementia and their carers http://www.nice.org.uk/nicemedia/live/10998/30318/30318.pdf NICE TA217: Technology appraisal http://www.nice.org.uk/nicemedia/live/13419/53619/53619.pdf BNF: Information on cautions, side effects and interactions http://bnf.org/bnf/bnf/current/61145.htm Electronic Medicines Compendium Summary of Product Characteristics for individual drugs www.medicines.org.uk NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 43 of 67 Version 3 08/12/2011 Formulary Status Approved (First Line) Drug Donepezil Initial Dose Maximum Dose Formulations Available Cost of 28 days treatment Tablets £2.19-£2.89** Orodispersible tablets £36.49£50.85** Comments 5mg once daily at bedtime 10mg daily Orodispersible tablets should be placed on the tongue, allowed to disperse and swallowed. Galantamine 8mg once daily (modified release capsules) 24mg daily (modified release capsules Modified release capsules £51.88£79.80** Also available as oral solution (see below under restricted drugs) . Rivastigmine 1.5mg twice daily 6mg twice daily Tablets £48.86£56.52** If treatment interrupted for several days, reintroduce initial dose and increase gradually Rivastigmine has less potential for interactions than donepezil or galantamine – may be an advantage in polypharmacy. Also available as adhesive patches (see below under restricted drugs) and oral liquid (see below, not approved for initiation within the Trust) NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 44 of 67 Version 3 08/12/2011 Formulary Status Cost of 28 days treatment Initial Dose Maximum Dose Formulations Available Use only if Rivastigmine patient has adhesive swallowing patches difficulties or for those who are not tolerating side effects despite optimised oral therapy. 4.6mg/24 hour patch 9.5mg/24hour patch 4.6mg/24 hour patch £72.77** 9.5mg/24 hour patch £72.77** Use only if patient has swallowing difficulties 4mg twice daily 4mg/ml oral solution £67.20£201.60**** Drug Galantamine oral liquid 12mg twice daily Comments See BNF http://bnf.org/bnf/bnf/current/68984.htm for guidance on switching from oral therapy to patches. In patients with swallowing difficulties consider use of donepezil melt. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 45 of 67 Version 3 08/12/2011 Formulary Status Approved (but see comments) Drug Memantine Initial Dose 5mg once daily Maximum Dose 20mg daily Formulations Available Tablets Cost of 28 days treatment £34.50£69.01** Comments Memantine may be prescribed for service users who have moderate Alzheimer’s disease who are intolerant of or have a contraindication to AChE inhibitors or those with severe Alzheimer’s disease. Memantine is approved for use as monotherapy only and must not be prescribed as combination therapy with AChE inhibitors. Oral drops £17.36£69.44**** Memantine oral drops contain 10mg of memantine hydrochloride in each millilitre. Each actuation or ‘downward pump’ dispenses 0.5ml of liquid i.e. 5mg. All prescriptions for memantine liquid must be unambiguous and service users and carers must be counselled on how to use the pump correctly in order to minimise the risk of accidental dosing errors. ** Prices based on Drug Tariff November 2012 edition **** Prices based on BNF September 2012 edition 64 NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 46 of 67 Version 3 08/12/2011 Return to Contents Page Other drugs that may be considered in the management of bipolar disorder The drugs included in this section may be considered for the management of bipolar disorder. They have been included in this section because they do not fall into the BNF category 4.2.3 antimanic drugs. The doses of olanzapine, risperidone, aripiprazole and quetiapine stated in this section are for the treatment of mania only – for other indications see relevant section of the formulary or BNF. Signposts to local (GREEN) and national (BLUE) prescribing guidelines NICE CG38 Covers the use of antimanic drugs in the management of bipolar disorder http://guidance.nice.org.uk/CG38/Guidance/pdf/English British Association for psychopharmacology guidelines for bipolar disorder http://www.bap.org.uk/pdfs/Bipolar_guidelines.pdf BNF For initial doses, advice on dose titration, indications and side effects. http://bnf.org Electronic Medicines Compendium Summary of Product Characteristics for individual drugs www.medicines.org.uk NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 47 of 67 Version 3 08/12/2011 Formulary Status Drug Approved Sodium valproate Formulations Available Cost of 28 days treatment Refer to BNF and SPC for doses – doses vary depending on whether the service user is also taking enzyme inducing drugs or valproate. Tablets £0.65-£3.20** Dispersible tablets £0.98-£4.63** Modified release tablets: 600mg daily in 1-2 divided doses Modified release tablets: 2.5g daily Modified £9.78release tablets £40.74**** (Epilim Chrono®) Liquid: 600mg daily in 2 divided doses Liquid: 2.5g daily Initial Dose Maximum Dose Liquid Comments Licensed for the prevention of depressive episodes associated with bipolar disorder. Service users who are stabilised on lamotrigine may require dosage adjustments if other drugs are added or withdrawn from their treatment regimen – consult summary of product characteristics for details. £10.84£45.15** Sodium valproate is not licensed for use in bipolar disorder but Epilim Chrono may be useful where valproic acid (Depakote®) is a suitable treatment option but a once daily dose is preferable. Sodium valproate liquid may be useful where valproic acid (Depakote®) is a suitable treatment option but the service user has swallowing difficulties. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 48 of 67 Version 3 08/12/2011 Formulary Status Approved Drug Aripiprazole Initial Dose 15mg once daily Maximum Dose 30mg once daily Formulations Available Cost of 28 days treatment Tablets £96.04£192.08** Orodispersible tablets £95.74£191.48**** Comments Licensed for the treatment and prevention of mania. Liquid – restricted (see below) Olanzapine Monother apy for mania: 15mg daily Monotherapy for mania: 20mg daily Combinati on therapy for mania or preventin g recurrenc e in bipolar disorder: 10mg daily Combination therapy for mania or preventing recurrence in bipolar disorder: 20mg daily Tablets £4.17-£5.62** Orodispersible tablets (velotabs) £60.01£61.99** Tablets £2.85-£5.62** Oro dispersible tablets (velotabs) £30.00£60.01** Licensed for the treatment of mania, either as monotherapy or combination therapy. Also licensed for preventing recurrence of mania in bipolar disorder. Velotabs are 10% more expensive than tablets. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 49 of 67 Version 3 08/12/2011 Formulary Status Approved Drug Quetiapine Initial Dose Maximum Dose Treatment of mania in bipolar disorder: 50mg twice daily Treatment of mania in bipolar disorder: 800mg daily in 2 divided doses Treatment of depressio n in bipolar disorder: 50mg at bedtime Treatment of depression in bipolar disorder: 600mg daily Formulations Available Cost of 28 days treatment Tablets £2.73-£15.90** £2.73-£15.03** Comments Licensed for mania either alone or with mood stabilisers and for the treatment of depression in bipolar disorder. For the prevention of mania and depression in bipolar disorder continue at the dose effective for the treatment of bipolar disorder and then adjust according to response. Usual range 300mg-800mg daily in 2 divided doses. Can be taken with or without food. NB: also available as XL tablets for once daily administration but these should only be considered where where a rapid titration is required or where once daily administration would be beneficial. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 50 of 67 Version 3 08/12/2011 Formulary Status Approved Drug Initial Dose Maximum Dose Formulations Available Cost of 28 days treatment XL formulatio n: XL formulation: Treatment of mania in bipolar disorder: 300mg once daily Treatment of mania in bipolar disorder: 800mg once daily £79.33£211.12** Treatment of depressio n in bipolar disorder: 50mg at bedtime Treatment of depression in bipolar disorder: 600mg daily £31.57£158.66** XL Tablets Comments Absorption affected by food, to maintain consistent levels give as a single night time dose without food. Licensed for mania either alone or with mood stabilisers and for the treatment of depression in bipolar disorder. For the prevention of mania and depression in bipolar disorder continue at the dose effective for the treatment of bipolar disorder and then adjust according to response. Usual range 300mg-800mg as a single dose. Absorption affected by food, to maintain consistent levels give as a single night time dose without food. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 51 of 67 Version 3 08/12/2011 Formulary Status Approved Drug Risperidone Haloperidol Initial Dose 2mg once daily 0.5–3mg 2–3 times daily or 3– 5mg 2–3 times daily in severely affected or resistant patients Maximum Dose 6mg daily 30mg daily Formulations Available Cost of 28 days treatment Tablets £0.71-£19.25** Licensed for the treatment of mania. Orodispersible tablets £36.96£56.00** Oro-dispersible and liquid preparations are significantly more expensive. Liquid £31.10£93.29** £2.20-£21.78** Licensed for the treatment of mania. Capsules Tablets Comments Carry out ECG prior to commencing. Liquid £0.62£18.69**** *Usual dose for adults. Dose may vary for young people and elderly – see BNF for details ** Prices based on Drug Tariff November 2012 edition **** Prices based on BNF September 2012 edition 64 NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 52 of 67 Version 3 08/12/2011 Return to Contents Page Licensed Drugs approved for ‘off label’ use The following section contains information on licensed medications that are approved for ‘off label’ use within the Trust i.e. approved for use outside of their UK product license. The off-label use of a medicine should only be considered when there is no equivalent product, licensed for the indication, available, or when the licensed product(s) are ineffective or cannot be tolerated. Service users (and/or their carers) must be made aware that the medication is being used outside of its product license, the reasons for this and any known serious or common adverse drug reactions. Refer to the Trust unlicensed medicines procedure for further guidance on responsibilities on the prescribing and use of ‘off label’ medicines. Signposts to local (GREEN) and national (BLUE) prescribing guidelines Unlicensed Medicines Procedure http://nww5boroughsintranet/library/documents/unlicensedmedicinespr ocedure.pdf BNF For initial doses, advice on dose titration, indications and side effects. http://bnf.org Electronic Medicines Compendium Summary of Product Characteristics for individual drugs www.medicines.org.uk NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 53 of 67 Version 3 08/12/2011 Formulary Status Drug Approved (second line – see comments) Clonazepa m Approved for use in rapid tranquilisatio n whilst IM lorazepam unavailable Midazolam IM injection Initial Dose* 0.25mg daily Maximum Dose* 2mg daily as a single or divided doses. Refer to midazolam cascade training and dosage charts http://nww.5boroughspartnership.nhs.uk/basep age.aspx?PageID=12344 Formulations Available 500 microgram tablets Cost of 28 days treatment £0.97-£3.90** 2mg tablets 10mg/2ml injection Comments Approved for treatment of agitation in psychosis and mania where lorazepam is ineffective. Costs approx 58p per vial.**** NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 54 of 67 Version 3 08/12/2011 Formulary Status Restricted Drug Melatonin Initial Dose* Maximum Dose* Formulations Available Cost of 28 days treatment Comments Melatonin is available as a 2mg modified release tablet (Circadin®) which is licensed for short term treatment of primary insomnia in patients over 55 years. Circadin® is not approved for initiation in adult service users within the Trust. However, Circadin® may be used within the CAMHS service where use of melatonin is considered appropriate (prescription must specify that Circadin® is required - see prescribing advice below). G:\Corporate Pharmacy\Pharmacy Team\WORKING DOCUMENTS\Formulary\5BP melatonin prescribing advice ver01draFINAL 2009-10-28.doc Prices vary according to supplier. *Usual dose for adults. Dose may vary for young people and elderly – see BNF for details ** Prices based on Drug Tariff November 2012 edition **** Prices based on BNF September 2012 edition 64 NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 55 of 67 Version 3 08/12/2011 Return to Contents Page Formulary for Treatment of Minor Physical Ailments The following section of the formulary provides information on the preparations that are available for the treatment of minor physical ailments. If further advice is needed on the most suitable treatment for a particular patient please contact a member of the medicines management team. The Trust policy on the use of discretionary medicines may also be useful when considering the treatment of minor ailments. http://nww.5boroughspartnership.nhs.uk/library/documents/5BPdiscmedpolicy.pdf The usual doses stated are those for adults – consult the BNF for Children for the treatment of children and adolescents (http://bnfc.org/bnfc/index.htm) The following topics are covered: Laxatives Analgesics Indigestion remedies Sore throat remedies Barrier creams Emollients Non anti-microbial ear drops Non anti-microbial eye drops Treatments for warts, verrucas and coldsores Treatment of haemorrhoids Sunscreens Nutritional supplements NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 56 of 67 Version 3 08/12/2011 Return to beginning of minor ailments formulary Laxatives Constipation can be defined as the passage of hard stools less frequently than the patient’s normal pattern. Where constipation is confirmed to be a problem consider the following possible causes: Lack of exercise, diet, inadequate fluid intake, medication e.g. including analgesics (especially opioids), calcium or aluminium antacids, anticholinergics, antidepressants (especially tricyclics), antiparkinsonian drugs, calcium supplements, diuretics, iron preparations, antipsychotics. Where diet or lifestyle factors are thought to be contributory factors encourage the patient to increase dietary fibre (e.g. fruit, vegetables, fibre rich cereals and bread), take regular exercise and drink plenty of fluids. Where constipation is thought to be drug induced stop the causative drug where possible. Drug Usual dose Senna 7.5mg tablets: 2-4 tablets usually at bedtime. Low dose initially then gradually increase. Comments Stimulant laxative. Effect is usually seen within 8-12 hours, therefore bedtime dosing recommended. Suitable for short term use only – chronic use may result in electrolyte disturbance and atonic colon. Useful for treatment of drug induced constipation. 7.5mg/5ml liquid: 10-20ml, usually at bedtime. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 57 of 67 Version 3 08/12/2011 Drug Usual dose Sodium docusate Up to 500mg daily in divided doses (available as 100mg capsules or 50mg/5ml oral solution) Stimulant and softening properties. Suitable for short term use only. Useful in combination with senna for drug induced constipation where senna alone is ineffective. Ispaghula husk 1 sachet or 2 level 5ml spoonfuls in water 1-3 times daily. Bulk-forming laxative. Full effect may take a few days to develop. May be useful in chronic constipation, or where lack of dietary fibre may be a contributory factor. Adequate amounts of fluid essential to avoid obstruction. For immobile patients bulk forming laxatives may be less effective and may even worsen the problem. Contra-indicated in faecal impaction. 1-3 sachets daily in divided doses, usually for up to 2 weeks. Each sachet should be dissolved in 125ml water. Osmotic laxative Due to high cost should be reserved for use where other treatment options have failed. When Laxidol® is reconstituted with 125mls water it is fluid neutral and so patients must consume normal amounts of fluid in addition to Laxido®. (Fybogel®) Laxido® sachets Comments (see BNF for management of faecal impaction) NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 58 of 67 Version 3 08/12/2011 Return to beginning of minor ailments formulary Analgesics Tramadol should be avoided as psychiatric reactions have been known to occur and there is also an increased risk of serotonin syndrome when prescribed with antidepressants. Drug Usual dose Comments Paracetamol 500mg-1g QDS Maximum frequency is every 4 hours and maximum dose is 4g in 24 hours. Prescribe regularly before considering adding/changing analgesic. Ibuprofen 200-400mg TDS Do not prescribe for service users on lithium or who have renal impairment or cardiac disease. Use with caution in asthma (see BNF for full list of cautions/contra-indications) Consider need for gastroprotection if prescribed long term. May be useful in mild-moderate musculoskeletal pain, dental pain and dysmenorrhoea. Co-codamol 8/500 1 or 2 tablets four times a day Monitor for constipation and prescribe laxatives is necessary. Contains paracetamol. Regular paracetamol plus codeine when required may be more effective where paracetamol alone is not effective. Codeine phosphate 30-60mg four times a day if required. May be useful in addition to regular paracetamol where paracetamol alone is not effective. Monitor for constipation and prescribe laxatives if necessary. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 59 of 67 Version 3 08/12/2011 Return to beginning of minor ailments formulary Indigestion Remedies Offer lifestyle advice e.g. healthy eating, weight reduction and smoking cessation. Review medications for possible causes of dyspepsia e.g. NSAIDS, bisphosphonates, steroids. Drug Usual dose Comments Gaviscon® Advance 5ml QDS (after meals and at bedtime) For use in Wigan, Knowsley and St Helens localities only (use Peptac® at Warrington and Halton) Note high sodium content – caution in hypertension and congestive heart failure. Increases in sodium levels may result in reduced lithium levels. Peptac® 10-20ml after meals and at bedtime For use in Warrington and Halton localities only (use Gaviscon® Advance at other localities) Note high sodium content – caution in hypertension and congestive heart failure. Increases in sodium levels may result in reduced lithium levels. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 60 of 67 Version 3 08/12/2011 Return to beginning of minor ailments formulary Sore Throat Remedies Drug Usual dose Simple linctus 5ml TDS Strepsils® Dissolve one lozenge slowly in the mouth every 2-3 hours. Comments An urgent full blood count should always be performed for any service user presenting with a sore throat and who is prescribed any medication with the potential to suppress bone marrow e.g. clozapine, carbamazepine. Barrier Creams Drug Usual dose Conotrane® cream Apply to the affected area several times a day as often as required. Comments NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 61 of 67 Version 3 08/12/2011 Return to beginning of minor ailments formulary Emollients If emollients are being applied to the whole body twice daily adults may need 600g per week. Creams are more cosmetically acceptable than ointments. Gels are particularly suitable for application to the face and scalp while lotions may be preferred for application to hairy areas. Ointments are much less likely to sensitise and are suitable for chronic dry lesions. Drug Usual dose Comments Oilatum® emollient bath additive Add 1-3 capfuls to the bath. Caution – this will make the surface of the bath slippery. Aqueous cream Use as a soap substitute Should only be used a soap substitute by wetting the skin, washing with the cream and then rinsing off. Do not use as a leave on emollient as this may result in skin thinning. Dermol® 500 lotion Apply after bathing and as often as required. Use when a less greasy emollient required. Can also be used as a soap substitute. Contains an antimicrobial. Hydromol® Ointment For use as an emollient, bath additive or soap substitute. Use when a greasier emollient required. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 62 of 67 Version 3 08/12/2011 Drug Usual dose Doublebase® gel Apply after bathing and as often as required. Comments Use when a greasier emollient required. Non-antimicrobial Ear Drops Drug Usual dose Comments Olive oil drops 3 drops 2-3 times daily. For the treatment of excess ear wax. Allow to warm to room temperature before use. Syringing may also be required once the wax has been softened. Sodium bicarbonate 5% drops 3 drops 2-3 times daily For the treatment of excess ear wax. Syringing may also be required once the wax has been softened. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 63 of 67 Version 3 08/12/2011 Return to beginning of minor ailments formulary Non-antimicrobial Eye Drops Drug Usual dose Comments Hypromellose 0.3% drops One or two drops three times a day as needed. Do not use if soft contact lenses are being worn. Use first line due to lower cost. Liquifilm Tears® One or two drops as required. Do not use with soft contact lenses (remove lenses prior to insertion and wait at least 15 minutes prior to reinsertion.) Viscotears® Liquid Gel One drop 3-4 times daily. Contact lenses should not be worn whilst the drops are being instilled. There should be an interval of at least 30 minutes before reinsertion. Treatment for Warts, Verrucas and Coldsores Drug Usual dose Comments Salatac Gel® Apply once daily at night. For the treatment of warts, verrucas, corns and calluses. Treatment may take up to 12 weeks for resistant lesions to disappear and it is necessary to persevere with treatment. Aciclovir 5% cream Use 5 times a day for 510 days at first sign of attack. For treatment of coldsores. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 64 of 67 Version 3 08/12/2011 Return to beginning of minor ailments formulary Treatment of Haemorrhoids Drug Usual dose Comments Anusol cream/ointment Apply to the affected area in the morning, at night and after each bowel evacuation until the condition is controlled. For the relief of uncomplicated internal and external haemorrhoids. Anusol suppositories Remove wrapper and insert one suppository into the anus in the morning, at night and after each evacuation. For the relief of internal haemorrhoids. Suncreams All antipsychotics have the potential to cause photosensitivity. There is no reliable data comparing the different antipsychotics but chlorpromazine is known to be the worst. Prescribe factor 40 or greater sunscreen for all inpatients prescribed chlorpromazine or other phenothiazines, and for those prescribed other antipsychotics that are thought to be at risk e.g. previous history of photosensitivity reaction. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 65 of 67 Version 3 08/12/2011 Return to beginning of minor ailments formulary Nutritional supplements Please note that different localities stock different brands of nutritional supplement (see table below for details) Seek advice from a dietician prior to prescribing wherever possible. Drug Usual dose Comments Fortijuice® Each bottle contains 200ml. Stocked at Warrington and Halton localities. Available as blackcurrant and orange flavours. See BNF for nutritional information. Forticreme® Each pot contains 125g. Stocked at Warrington and Halton localities. Available as forest fruits and vanilla flavours. See BNF for nutritional information. Fortisip® Each bottle contains 200ml. Stocked at Warrington and Halton localities. Available as strawberry, banana and chocolate flavours. See BNF for nutritional information. Ensure Plus® milkshakes Each bottle contains 220ml Stocked at Wigan and St Helens and Knowsley localities. See BNF for nutritional information. Available as banana, strawberry and vanilla flavours NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 66 of 67 Version 3 08/12/2011 Drug Usual dose Comments Ensure Plus® juice Each bottle contains 220ml Stocked at Wigan and St Helens and Knowsley localities. See BNF for nutritional information. Available as apple, pineapple, lemon and lime flavours Ensure Plus® Crème (yoghurt) Each bottle contains 220ml Stocked at Wigan and St Helens and Knowsley localities. See BNF for nutritional information. Available as chocolate and vanilla. NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links should be reported to the medicines management team. Page 67 of 67 Version 3 08/12/2011